Do doctors know enough about travel insurance?
Do general practitioners or family physicians know enough about travel insurance? Milan Korcok examines the reasons why it’s vital they know more.
“I’m trying to be honest, but my doctor doesn’t tell me everything.” As a travel insurance ombudsman for over 10 years, I have heard this complaint from many embittered travellers whose claims for medical and hospital expenses have been denied by their insurers because their medical histories didn’t match their applications for coverage. Perhaps they didn’t check off the box asking if they had been treated for cardiovascular abnormalities, or gastrointestinal disorders, or urinary or kidney complaints, or lung conditions, or any number of other conditions within the past one, two, or five years; or they failed to report their last visit with their family physician; or they didn’t understand what their doctor said when he talked about their dyslipidemia; or, perhaps, they just brushed all other advice aside once he blessed them with a ‘clean bill of health’. And then came the denial of their claim.
Were they liars, cheats, frauds? Did they deserve to be caught out? Or were they just unwitting victims of a dynamic in which doctors, trying to clear their waiting rooms, didn’t take the time to explain all their test results, or didn’t consider the results clinically significant, or just didn’t want to bother their patients needlessly. Perhaps the doctor just felt they were better served by a good vacation in the sun than by learning an inconvenient truth.
Case Illustration
An elderly gentleman from Canada flew to Australia where, just days after arriving, he was admitted to hospital for shortness of breath, coughing spasms, exhaustion, and loss of appetite. Radiological examination revealed multiple nodules and masses throughout the lungs; additional examination revealed cancer in the lungs, liver and other organs. Suspecting a pre-existing condition, the insurer requisitioned the patient’s medical records from Canada and found that within 180 days of his trip, the patient made several visits to his family doctor for treatment of persistent cough, lack of appetite, and constant wheezing, and chest x-rays showed ill-defined areas of increased density in the left lobe of the lung ‘perhaps representing partially calcified granulomas’.
The insurer denied the claim on grounds that the policy didn’t cover any pre-existing conditions that manifest symptoms, were unstable, or were treated or investigated within 180 days of the effective date of coverage.
Doctors, on the other hand, have a panoply of reasons for wanting to give a clean bill of health
In challenging the denial, the patient’s family contended that prior to his departure, their father had not been specifically diagnosed with any medical condition, and his doctor had given him a health clearance to travel. In their appeal, they appended a letter from the family doctor, which stated that he and his associates had examined the patient and saw ‘nothing on his examination to indicate a health concern’. He was advised to see them again when he returned. He died shortly after his return.
Certainly, the claim denial came as a cruel blow to the family as well as a potentially catastrophic financial loss. As a member of the family later noted to me, his father would not have travelled without his doctor’s medical clearance or if he had known what the x-rays revealed.
Appropriate disclosure
Contrast this with a family physician who tells her patient that though she does not believe the finding of a kidney stone may be the proximate cause of a persistent lower right abdominal pain – that it might just be an incidental finding – he should check with his travel insurer if this might affect his coverage on a pending snowbird trip to Florida. In this case, the client did not follow his doctor’s advice, mentally locked on instead to his doctor’s opinion that the stone was irrelevant or ‘incidental’, and when completing his medical application failed to check off the box that asked if he had been treated or investigated for ‘urinary or kidney disorders’ within the past 12 months. When several weeks later he presented to a US hospital with lower right abdominal pain and a clearly defined ureteral stone, it didn’t take much investigation to justify a claim denial on grounds both of pre-existing condition and non-disclosure.
Insurance applicants, especially elderly snowbirds in less than perfect health, are acutely aware that the more ‘Yes’ boxes they tick off on their medical applications, the higher their premium tends to go. So there is a subliminal pressure to seek out reassurance that they are OK. And when their family physician says, or even hints, that he or she sees no reason why they should not take their annual five- or six-month vacation in the sun, that seems a lot more persuasive than a mass of fine print in a long contract defining abstract terms like ‘pre-existing condition’, or ‘stable and controlled’, or ‘treatment and referral’. It’s easier. It’s what patients want to hear. And who doesn’t trust their family doctor?
Doctors, on the other hand, have a panoply of reasons for wanting to give a clean bill of health. The first is that it makes their patients happy. Another is that they have neither the time nor the inclination to read their patient’s travel insurance policies. Who does, when some of these run to more than 30 pages?
But in Canada, where universal, comprehensive provincial health plans cover only a small share of out- of-country emergency medical services, private, supplemental travellers’ insurance is a fact of life. More than 80 per cent of snowbirds buy it, and each year Canadian seniors make close to one million out-of- country trips of at least 30 days. There are few Canadian family physicians who don’t have some snowbirds on their patient rolls. And though there are literally hundreds of different plan options available, the basic concepts of each of these plans are quite similar, as are the definitions and rules about disclosing medical conditions, or treatments, referrals or changes of medication, or guidelines for covering pre-existing conditions; or reporting any health status changes after a policy is purchased and before it is activated (many snowbirds buy months in advance to take advantage of cheaper prices).
Most doctors now are responsible in sharing all facts and diagnoses with their patients
The wording differs slightly, depending upon how many lawyers can dance on the head of a pin, and the exclusionary periods for pre-existing conditions vary (i.e. 30 days, 90, 180); so do the eligibility requirements. But the constant in all policies is that travel insurance is for unexpected emergencies, not conditions or symptoms that already existed or had been treated or were being investigated without the insurer’s knowledge.
Doctors onboard
No-one expects busy doctors to spend their evenings reading insurance policies, but if they recognise that policies define limits of coverage, and those limits don’t necessarily coincide with how physicians assess and disclose their patients’ status, they might moderate their tendency to hand out clean bills of health, or decide on their own what is or is not clinically significant enough to tell the patient. Dr Robert MacMillan, a former president of the Ontario Medical Association, and medical director of Medipac International, one of Canada’s leading vendors of snowbird insurance, says: “It no longer is the physician’s prerogative to conceal abnormal results from the patient, even if deemed trivial, not just because of insurance applications but because we live in a time of ‘the right to know.’” He adds: “Most doctors now are responsible in sharing all facts and diagnoses with their patients as required by their professional colleges, but there are certainly still some of the old school where such information is not shared.”
Right to know
When I speak to claimants about what they ‘didn’t know’, many say they feel caught in a vice – wanting to be open and truthful, but unable to be so. Some have said that had they known what their doctors knew, they would not have travelled because – unlike their doctors – they know about travel insurance exclusions and limitations. They have been around the block.
in adjudicating a claim, most insurers will require copies of the physician's notes to confirm benefits
Do they have any recourse if they feel victimised by a claim denial that was not their fault? Dr MacMillan notes that in adjudicating a claim, most insurers will require copies of the physician’s notes to confirm benefits and these are required by their professional colleges to be legible. Furthermore, he says: “The physician could be liable … (for) any information of significance not revealed to the patient (that) may have resulted in a faulty application and denied claim.” He adds: “It is important for physicians to be aware of this potential when abnormalities are found during examination or investigation.”
As insurers expand their options for people in less than perfect health, medical underwriting and the applications and requirements that are part of that process place more burden on potential insurance purchasers. Ultimately, it is they who are responsible for the accuracy of the medical applications they declare and sign. They can’t blame a misleading, or untruthful, or incomplete application on someone else.
Most insurers now advise applicants who are unsure of their medical status, or what the questions mean, or the terminology used, or what lurks in the depths of their medical records to ask their doctors to look over their responses. Some insurers also require applicants in the highest risk groups to have their doctors complete their medical questionnaires.
It’s clearly much safer for some applicants to ask their doctor for help in completing an application, even if they have to pay a fee for the service. Says Dr MacMillan: “Perhaps fewer claim denials would occur if insurers attached a short note to the attention of the doctor when such assistance is needed.”
But insurers, too, have to ask themselves how much they can expect of purchasers who just want to ‘get insurance, get it cheap, and get the hell out of the snow’. They realise that medical applications and underwriting tools need to be clearer, simpler, more manageable by applicants as well as precise and probative enough to reflect an honest and accurate picture of their risk factor. As most will admit, they need to do a better job of getting the medical information they need to assess risk without requiring their applicants, many of them elderly, to jump through increasingly high hoops.
Busy doctors are not going to set aside time they could be treating patients to pick up a syllabus on travel insurance. But perhaps it’s not unreasonable for generalists and family practitioners to brush up on the basic concepts of what travel insurance is designed to do, how it is structured, and to understand that its purpose is to supplement out-of-country coverage and not to be a substitute for domestic medicare.
It may also be reasonable for physicians to admit to their patients that they can’t qualify them for travel insurance, or tell them if they should or should not travel. It may hurt some doctors’ egos to deny such powers of benediction, but they are not the ones who pay the bills if their patients end up in a foreign hospital.
But their actions, when dealing with travelling patients, do have potentially serious consequences of which they may not be aware. Patients need to remind them of one of the most basic principles of their art: First, Do No Harm.